Just a glance at a map is enough to determine why Morocco is in the throes of an epidemic of injecting drug use. Sitting at the gates of Europe, its northern-most cities of Tangier, Tetouan and Nador are but a stone’s throw from the Spanish territories of Ceuta and Melilla: the crossroads of the African migration routes where all kinds of trafficking occur.

« There’s cannabis leaving Morocco and other drugs coming in from abroad, » explains Faoizia Bouzzitou, the educational coordinator for the Hasnouna Association to Support Drug Users (AHSUD in French).

In Tangier, AHSUD provides assistance to around 1,700 people who inject drugs, helping to dissuade them from sharing needles and engaging in other risky behaviors that put them at risk for HIV infection.
Such harm reduction programming is unique to Arab countries but has demonstrated results that show it can, and should, be replicated. HIV prevalence among the drug users of Tangier is just 0.4% — in stark contrast to Nador, a city 400 km to the east that launched its harm reduction work a few years later, where HIV prevalence among drug users is above 20%. The divergent figures contribute to a national estimate of 10% sero-positivity among injecting drug users.

AHSUD began its work in 2007 with a bio-behavioral survey and a mapping of the injection sites in Tangier, says Bouzzitoun. « We needed to know who we were talking to, and the extent of the problem. You need an evidence base before you talk to decision-makers. »

These data were also the basis for AHSUD’s successful application for Global Fund support, to purchase injection kits to stock a mobile unit: a modest van into which four staffers would climb every day and prowl the squats and hidden spots where drug users would converge to get their fixes.

Our sons and daughters

« We started downtown, in the M’sallah quarter, where most of the heroin users stay. They were shooting up in front of people’s houses, leaving their syringes where kids could play with them. Some young girls were even using the syringes to give henna tattoos, » recalls Bouzzitoun. « So part of the early effort was to work with drug users to change their behavior. We gave them single-use, sterile needles. We taught them about the risks of infection, and other risks like TB, or HIV or Hepatitis C. And we showed them how to shoot up in the least risky way, and avoid overdose and how to figure out an alternative when they don’t have works to fix. We are trying to point them towards health centers. »

It is there that the association finds some of its biggest challenges, confronting the stigmatization of injecting drug use. Be it by health professionals, including doctors and pharmacists, police, or the general public, they are finding it a painstaking and slow process to change people’s minds. With door-to-door campaigns, field teams gently demonstrate the importance of harm reduction to Tangier’s citizenry.

« It’s because drug users are someone’s sons, someone’s daughters, » says Bouzzitoun, that it boils down to a simple choice: « do you want them to be able to inject safely, with a chance to get off the drugs, or do we want them to be exposed to Hepatitis C, to HIV, and to risk spreading these illnesses to society? »

AHSUD has also opened a field office in Hasnouna, providing a quiet and clean place for drug users to take a shower, wash their clothes, have a cup of coffee and, hopefully, participate in a support group session.

Morocco’s journey to realizing the benefits of harm reduction programming has been a long and slow one. In 2010, opioid substitution therapy with methadone was launched in Tangier, Rabat and Casablanca: another program that received funding from the Global Fund as well as the Ministry of Health. And while methadone is no silver bullet, it helps reduce the risk of disease simply because it isn’t consumed intravenously. « So for 48 hours, a drug user can work, or shower, or eat — basically functioning like a regular person, » says Bouzzitoun.

The light at the end of heroin’s tunnel

Today, by broad consensus, AHSUD’s work is bearing fruit. « People we interviewed [for this documentary] say that it is not like it was before; there are fewer users, fewer drug injectors, less crime and less theft, » Bouzzitoun says proudly.

Also evolving is the mentality and attitudes of those who operate in the drug users’ orbit — specifically the police. « Now when a drug user is arrested, we get notified automatically by the police, who ask us to come and see if he needs treatment, » she says.

Risky behavior among drug users is also on the wane. Almost all of the injecting drug users supported by AHSUD use the kits of works they are given — syringe, spoon, filter, cotton and sterile water — and regularly participate in needle exchange. Among them are 400 people enrolled in a methadone program at the Medical Psychological Center next door.

These measures have really made the difference in helping bring down the HIV prevalence in Tangier’s drug-taking community. Also a contributing factor, said Bouzzitoun, is the HIV testing that around 80% of the people in the program have undergone. « We’ve done regular testing twice a week, every week, since 2008, » she says.

Now that the Tangier program has demonstrated such positive results, it was only natural that the program be extended to other major cities, beginning with Tetouan in 2009 and now Nador, Casablanca and Rabat.

But that doesn’t mean that all of the problems associated with injecting drug use have been resolved. Hepatitis C, which afflicts more than half of the people who inject drugs, remains a threat. AHSUD has yet to be allowed into prisons and new drug users — kids aged 15 and 14 and, sometimes, even 13 — aren’t getting access to the group’s kits because they will require parental consent.

Even the methadone program, despite its excellent results that allow more than two-thirds of participants to return to a regular life once they’ve kicked their habits, is coming up short, not able to meet the needs. In Tangier alone the waiting list is more than 900-strong.

« Most users want to get off the drugs », AHSUD says, but there aren’t enough services available to them in the region: not enough treatment, not enough staff and not enough options within the health system to meet demand. The Medical Psychological Center, which works alongside AHSUD, must oversee the methadone treatment of 350 people and is not accepting new clients.

Tangier, MENA’s harm reduction laboratory

The first country in the Middle East and North Africa to introduce both harm reduction and methadone programs, Morocco is now sharing its experience through a training center also run by AHSUD in Tangier.

In addition to providing technical support to their colleagues in Tetouan and Nador, AHSUD has brought in groups from Tanzania, Senegal, Tunisia, Algeria and Libya, sharing the experiences and lessons learned since 2007 with doctors, decision-makers and representatives from civil society.

They exhort the need for an evidence base, and provide guidance on how to forecast and plan to ensure that donors see the possibility for results. But mostly they plead for interlocutors to remember that people who inject drugs are just that: people. « We are trying to teach people how to approach users, how to talk to them and earn their trust, » says Bouzzitoun. « Because that is the only way you can reach them. »

In a shaded courtyard of a non-descript building just on the outskirts of Nouakchott, a group of young men sits in comfortable repose. It’s a group with no official name, only the whispered identity of an MSM: a man who has sex with men. One by one they get up to sit on an overturned bucket and tell intimate details of their lives.

They are providing anonymized responses to two employees of the NGO SOS Pairs Educateurs as part of Mauritania’s first Integrated HIV Bio-Behavioral Surveillance (IBBS) survey since 2007.The data collected by the IBBS survey will help the national AIDS commission, SENLS, to develop its concept note for some $32 million allocated by the Global Fund to Mauritania under the new funding model (NFM). A first data collection in seven years will clarify the state of the disease and its response in the Islamic republic, both within the general population and those groups most exposed to the risks of infection: groups like commercial sex workers, prisoners, members of the security forces and truck drivers who travel the length of the West African corridor or across the northwestern deserts of the Sahel. Other high risk groups include economic migrants, sailors and the fishing industry.

But it’s the men who have sex with men who are the hardest to reach, even for the survey, in this very conservative society. « It’s impossible to say the word homosexual in public, » explains Fatimata Ball, who represents people living with HIV on the Mauritanian country coordinating mechanism (CCM). Ball is one of just two people in Mauritania who appear bare-faced when they talk about their HIV-positive status. With her head held high she daily battles discrimination on behalf of her fellow citizens living with the disease, and the taboos that complicate everything — especially anything to do with homosexuality. »They’re [considered] horrible people who we shouldn’t engage with — not even to shake their hands because for 40 days afterwards, your prayers will be worth nothing, » she says, shaking her head ruefully.

A ‘foreigner problem’

Officially, Mauritania is one of 11 countries worldwide where being gay is punishable by death. In reality, this penalty has not been applied against anyone since 1987. Conventional wisdom is that the country is not nearly as harsh in its perception of homosexuality as countries like Iran, or even southern neighbor Senegal. And Fatimata Ball is quick to say that religion — Mauritania practices a strict interpretation of Sunni Islam — doesn’t bear all the responsibility. « We’ve got the big religious leaders who are saying that, even if Islam condemns these practices, these are human beings who have the right to treatment, » she says. « But what they’re not doing is saying it publicly: not on the radio, or in the newspapers, or even during their sermons. They’re not saying it so people can hear, and so people aren’t frightened. »

The silence is an advantage to the people working on the frontlines as well. « We don’t want to make noise around our work; our society doesn’t like too much buzz, » says Jibril Sy, president of SOS Pairs Educateurs, which has been working quietly in the gay community since 2001. « When we started our work, we knew that it would be a bad strategy to attack the law, » he says. « So we have really taken the angle of right to health, which works here. No matter who you are, even if you’re a stranger, Mauritanians believe you have a right to health. »

Most don’t, however, believe that HIV is a ‘Mauritanian thing’ but rather an uninvited import from neighboring countries, carried by people who fled Senegal or the Gambia to become refugees here. They think that those foreign elements are also responsible for the introduction of homosexuality into Mauritanian culture, reflecting their disharmony with the way things really are. According to Amadou Seye Ndiaye, himself of Senegalese origin, « if you behave normally, you should have no problems. But these new guys, they are bringing us trouble. They dress up in women’s clothings, they wear makeup, and they get married — like in Senegal. »

Ndiaye is a self-styled representative of the Nouakchott gay community, in which he says he knows about 400 people — incuding about 100 Mauritanians. Among them are many who use his home as sort of a drop-in center. It is here that SOS Pairs Educateurs are carrying out their survey, and it is here that Yacoub and Ahmed (not their real names) explain how the gay community in Nouakchott is changing.

« There are a lot of men in Mauritania who have sex with other men, but we are very, very discreet. We can be the masters of ceremony at weddings and celebrations of birth but beyond that, we try not to attract attention, » says Ahmed. « But the Senegalese, they are very provocative, very daring. And it shows, and it shocks, and it causes a lot of people to revolt against them. »

Leaving the shadows behind, and being heard

« More and more we see gay men coming and asking for services from civil society, » says Aliou Diop of SOS Pairs Educateurs. What this means, according to Diop, is that if the state is allowing groups like his to respond, it’s that the state understands that the national response must accommodate all of the different needs. And the needs are growing, according to the preliminary results of the survey, which have yet to be made public, the HIV infection rate in the gay community is on the rise, likely to substantially exceed the 5% infection rate recorded in 2007.

Nothing proves the importance of reacting to an epidemic before it spreads beyond a concentrated population to the general population than a rise in infections, but Jibril Sy says there are very few, if any, activities being carried out across the country. This is due to the challenges that followed a damning Office of the Investigator General report from 2009. Suspension of the grant meant a loss of direction (learn more) and ultimately resulted in very little effort to target prevention activities to one of the communities that needed them most.

The new funding model (NFM) is providing Mauritania with a previously unanticipated opportunity: to wipe the slate clean and demonstrate its new capacity for risk management while also changing its strategy, and its approach, to HIV. This means a bigger ask — some $11 million — for innovative new programs that put key populations at the heart of the response. But even this is not without challenges because even condom distribution has to be done covertly (PDF – 600 Kb – p. 16) through people who volunteer to keep the products hidden in their homes.

Saving face or saving lives

How to encourage men who rely on the shadows to step into the light, to risk harassment, arrest and discrimination remains the unanswered question. Senegalese expat Madieng says it’s about coming together as a community. « If we’re in a bloc, we will have a strong coalition, with a strong leader who knows the problems and can speak on our behalf, » he says. « It is up to us to help ourselves; we can’t wait until society accepts us — we just want to be left in peace and treated like human beings. »

But another sign of the disconnect between the new arrivals and the indigenous community is revealed with Yacoub and Ahmed’s almost immediate rejection of the idea. « We don’t think that coming together will serve any purpose, because we are fine just helping each other. We don’t have any specific problems that require us coming together, forming an association, being represented by some guy, » they say.

For now, some short-term plans are in place, if only to establish what activities should be prioritized under the concept note using focus groups comprised of those who responded to the IBBS survey. This has been approved not only by the CCM but by the Fund’s own country team, which has emphasized the need for these proposals to come from the local context. If in Mauritania that means individuals, not formal or even public groups, that will work, as long as it is a participatory approach, the Global Fund Secretariat emphasized.

While being back in the good graces of the Global Fund will be critical to Mauritania’s HIV response, it is far from a magic bullet that will see an opening of Mauritanian society to homosexuality. « With or without funding, there is never going to be a legal recognition of the rights of men who have sex with men or sex workers, » says Fatimata Ball. « That’s non-negotiable in an Islamic country and no amount of money is going to change how Mauritanians feel about this. »

https://i2.wp.com/www.bourgoing.com/wp-content/uploads/2014/12/IMG_2495_OK_700x300.jpg?fit=700%2C300300700Robert Bourgoinghttp://www.bourgoing.com/wp-content/uploads/2017/06/logo05.jpgRobert Bourgoing2014-12-17 16:10:422015-09-04 09:50:03Mauritania, the Global Fund and the discreet inclusion of the gay community in the HIV response

Objectively, Morocco’s HIV indicators paint a relatively reassuring picture of a country only grazed lightly by an epidemic that has had ruinous consequences elsewhere in Africa.

Prevalence rates have never risen above 0.2% and, for the most part, only a small sub-section of the population is really at risk of infection: members of those globally identified vulnerable groups, including sex workers, men who have sex with men and people who inject drugs.

But delve a little deeper and the picture is not as rosy — because among those vulnerable groups, there is serious danger in the unknown. Three in four of Morocco’s most at-risk do not know their status, according to Dr Abdelaziz Ouassadan, coordinator of the diagnostics department at the Association for the Fight Against AIDS (ALCS). And while Morocco’s human rights record is improving (read Morocco’s quiet revolution over AIDS and human rights), stigma and discrimination continue — so finding them is like searching for a needle in a haystack.

« It’s really challenging, in the context of a 0.1% prevalence rate, to find 30,000 people, » he said during a recent visit. « Think about just how many tests you would have to do to find 100% of the infections. »

Since 1992, ALCS has been responsible for most of the diagnostic testing in Morocco. But of course it cannot be responsible for testing all 30 million people in Morocco alone and, despite all of the awareness campaigns of the last decade, many of which received Global Fund support, voluntary testing remains rare. A goal of reaching 80% of both men who have sex with men and sex workers seems far off.

Rather than abandoning the effort, however, the Moroccan government is putting more resources into achieving the diagnostic goals. A ‘know your status’ campaign is at the heart of the national strategic plan (in French) for 2012-2016, and includes an arsenal of activities, education and community mobilization led by grassroots organizations that know their clientele: the clandestine and vulnerable key populations. Taking diagnostics out of the hands of medical professionals and putting them into the hands of community health workers is another innovative component of a program currently in development.

Overcoming fear and ignorance

Since 2013, ALCS has joined other sub-recipients of Global Fund support such as OPALS (in French) and the Southern Association Against AIDS (ASCS – in French) in pivoting towards working exclusively on the issues affecting key populations. In Morocco’s large cities and priority regions, teams of educators work directly in the communities of vulnerable populations, developing trust and affinity as they encourage people to get tested.

In Agadir, it is teams of women who are sent by ASCS into the red light zones where sex workers ply their trade. Equally, ALCS is doing its part to reach the truck drivers who form the largest part of the sex trade client base and those who are most likely to pass infections into the general population.

Work in this population has shown some modest result, said Dr Fatima Zahara, who heads the truck driver outreach program. The number of sex workers visited on average by a truck driver has declined from nine to six since 2007, and higher condom usage has been recorded. Truck drivers are also more inclined to get tested than they were before, she said, and they are taking fewer risks.

« I got tested, like almost half of the others in the [Association of Truck Drivers] because ALCS encouraged us to and brought the mobile clinic to make it easier, » said Taoufik Choukri as he relaxed next to his rig at a truck stop in Petromin, Agadir’s industrial zone.

NGOs have had to be more innovative in their efforts to reach the Moroccan gay community, which remains in the shadows for fear of stigma and persecution.

« There are a lot of people we have not been able to reach, who use chat sites, » said Abdoullah Tif, who manages the web presence for ALCS. It was at Tif’s initiative, therefore, that ALCS has created a profile on PlanetRomeo, the most popular site for gay men in Morocco. « If you’re gay and can read and write, you’re on PlanetRomeo, » Tif said. ALCS now has an profile it uses to reach out to the more than 13,000 Moroccan users, to chat anonymously and share health information on topics such as HIV education, invitations for people to come to the ALCS office, and subtle encouragement for people to get tested and know their status.

But for all the innovations and efforts to overcome HIV-related stigma, it remains a complicated proposition to reach the people most vulnerable to infection, said Mouna Balil, who runs ALCS programs in Marrakesh, the country’s third-largest city.

« We’ve had a tough time finding doctors. Some of them have said very clearly that they will help us carry out diagnostic testing — but not with men who have sex with men, » she said. So how to bridge the gap between a medical community that is still stigmatizing homosexuality and a gay community staying firmly underground poses a critical challenge.

For ALCS, it means removing doctors from the equation. A new program about to get under way will provide training to community volunteers in diagnostics and counseling, so that people can work directly with their peers.

The volunteers use a simple finger-prick test, deriving immediate results from a single drop of blood.

« In light of the need, the Health Ministry has approved the program, » said Younes Yatine, who leads the prevention campaigns for ALCS within the gay community. « Now it’s up to us to find the right volunteers, to provide the right kind of training, and to have the right start to the campaign. »

These community-led diagnostic programs should only be one among a number of different activities, cautioned Boutaina El Omari, who is the Global Fund focal point for the Ministry of Health « It’s not the one and only solution, » she said. « Studies have clearly shown that even with the tremendous effort being made by the NGOs, they will never reach everyone. »

So for now the ministry will continue with other strategies that have worked in the past: annual diagnostic campaigns that target the entire population with ads on social media, television and radio. While expensive, this campaign has seen the number of HIV tests administered skyrocket, from 70,000 to more than 500,000 per year. And while just 300 new infections were identified in 2011, another 1,100 people were diagnosed in 2012, and 1,200 in 2013. These campaigns have also helped bring down the numbers of people who are unaware of their HIV status, from 80 to 75%. « We’ve been an interesting case study for the World Health Organization, » said El Omari. « They have hypothesized that where there is a low infection rate, generalized campaigns don’t work; we are evidence to the contrary. »

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It is now clear that Russia, Mercer, and others orchestrated a comprehensive campaign to undermine the democratic process in the UK and United States, and it seems implausible, given the evidence, that both Trump and Brexit were not in some way an outcome of this. – par Tobias Stone – Tags: cambridge analytica, info warshttps://medium.com/@tswriting/nothing-is-real-anymore-116945eacb45

Sleep Walking into a War: Part 4
One reason the Great Cyber War is hard to understand is that victory in the eyes of the aggressors is not some final outcome where one side wins and the other capitulates. Whereas Hitler wanted to take over the world, Putin and the billionaires just want to create and perpetuate chaos. – par Tobias Stone – Tags: cambridge analytica, info warshttps://medium.com/@tswriting/what-victory-looks-like-8b715545e820

How YouTube became a breeding ground for violent, sexual and disturbing content targeted at YOUR kids
AN ANIMATED Minnie Mouse lookalike injects a knock-off Mickey Mouse character with a syringe, as a blood-curdling scream rings out. Later in the same clip, the camera zooms in on an animated mouse’s bouncing breasts as suggestive music plays. – par George Harrison – Tags: ai, info wars, youtubehttps://www.thesun.co.uk/tech/4864071/youtube-violent-sexual-disturbing-video-children/

?FakeTube: AI-Generated News on YouTube
One of the results of my recent post-election “news ecosystem” effort was the presence of YouTube. Beyond YouTube’s role in hosting videos through embeds on political websites, after reading a piece on A.I. – par Jonathan Albright, Learn – Tags: ai, fake news, info wars, tech, video, youtubehttps://medium.com/@d1gi/faketube-ai-generated-news-on-youtube-233ad46849f9

“Fake news” has become a business model, researchers argue
This week Theresa May used a speech to tell Russia: “We know what you’re doing,” at least as far as the country’s efforts to spread discord through disinformation are concerned. – par Thomas McMullan – Tags: fake news, info warshttp://alphr.com/go/1007711

Russia’s Favored Outlet Is an Online News Giant. YouTube Helped.
SAN FRANCISCO — When the state-backed Russian news channel RT became the first news organization to surpass one billion views on YouTube in 2013, it marked the achievement with a retrospective of its most popular videos and a special guest — one of the Google-owned site’s senior executives. – par Daisuke Wakabayashi, NICHOLAS CONFESSORE – Tags: désinformation, info wars, youtubehttps://www.nytimes.com/2017/10/23/technology/youtube-russia-rt.html

Information Disorder: An interdisciplinary framework
Our new report for the Council of Europe aims to bring structure to conversations about misleading and malicious information. – Tags: info warshttps://firstdraftnews.org/coe-report/

Anatomy of a Russian Facebook ad
On Wednesday, lawmakers released some of the 3,000 ads that Russian operatives bought during the 2016 presidential campaign and its aftermath. Facebook has said these ads were created by the Internet Research Agency, a troll farm in St. Petersburg, with the goal of influencing U.S. – par Leslie Shapiro – Tags: facebook, fake news, info warshttps://www.washingtonpost.com/graphics/2017/business/russian-ads-facebook-anatomy/

Trolls, Bots and Fake News: The Mysterious World of Social Media Manipulation
If it was once common to hear mass anti-government movements in the Middle East described as “Twitter uprisings” and “Facebook revolutions,” today these social media platforms are more likely to be linked to their potential for manipulating public opinions and influencing elections, includ – par Samuel Earle – Tags: cambridge analytica, fake news, info warshttp://www.newsweek.com/trolls-bots-and-fake-news-dark-and-mysterious-world-social-media-manipulation-682155

Russian Trolls Didn’t Just Flood Facebook with Fake News—They Faked the Accounts of Real Organizations
The problem is bigger than just ads. As Facebook is turning over information on Russian-bought ads to Congress, it’s becoming clear that the disinformation campaign was much more sophisticated than just spreading fake stories about the Clintons killing an FBI agent. – par Luke Darby – Tags: facebook, fake news, info warshttps://www.gq.com/story/russian-trolls-facebook-accounts

How the Hashtag Is Changing Warfare
On the eve of last year’s U.S. presidential election, two computational social scientists from the University of Southern California published an alarming study that went largely unnoticed in the flood of election news. – Tags: bots, fake news, info wars, twitterhttps://www.afcea.org/content/how-hashtag-changing-warfare

The Agency
Around 8:30 a.m. on Sept. 11 last year, Duval Arthur, director of the Office of Homeland Security and Emergency Preparedness for St. Mary Parish, Louisiana, got a call from a resident who had just received a disturbing text message. – par Adrian Chen – Tags: fake news, info wars, social mediahttps://www.nytimes.com/2015/06/07/magazine/the-agency.html

This election had about 400,000 Twitter bots
Nearly 20 percent of Twitter’s election-related tweets were from bot accounts.Learn more about this story at www.newsy.com/64831/Find more videos like this at www.newsy.comFollow Newsy on Facebook: www.facebook.com/newsyvideosFollow Newsy on Twitter: www.twitter.com/newsyvideos – Tags: bots, info wars, twitterhttps://www.youtube.com/watch

We are not done with state-sponsored hacking. Far from it.
Last Friday, a few hours before the end of the French presidential campaign, and right at the start of the mandatory “quiet period” before the vote, Twitter erupted: A big dump of documents had just been released. – par Learn, Frederic Filloux – Tags: bots, cambridge analytica, désinformation, fake news, info wars, propagande, securityhttps://mondaynote.com/we-are-not-done-with-state-sponsored-hacking-far-from-it-55c8b2fc7fc6

https://i1.wp.com/www.bourgoing.com/wp-content/uploads/2015/05/KPRs-MorroccoCCM.jpg?fit=1000%2C5105101000Robert Bourgoinghttp://www.bourgoing.com/wp-content/uploads/2017/06/logo05.jpgRobert Bourgoing2015-05-28 12:28:382015-09-04 09:24:11More than a voice: invest in community representatives capacities to be heard